Unmada is a broad category which includes various psychiatric conditions and is characterized by deranged mental functions.[1]“Bhuta vidya” (Ayurvedic psychiatry) is a branch which deals with incantation and mode of exorcising, evil spirits, and making offerings to deva (divine beings), pishacha (class of demon fond of flesh), gandharva (class of demon fond of entertainment), yaksha (living supernatural being/ghost), and rakshasa (class of demon fond of violence) for the cure of diseases originating from their malignant influence.[2]Bhutonmada is a psychiatric condition and is characterized by various types of abnormal behaviors. Acharya Vagbhata has described 18 types of bhutonmada/grahonmada. They are deva, asura, rushi, guru, vruddha, siddha, pitru, gandharva, yaksha, rakshasa, sarpa, brahma rakshasa, pishacha, kushmanda, nishada, preta, maukirana, and vetala. Yaksha grahonmada (YG) is one among these 18 types of grahonmada.[3]

Till date, no studies have been conducted on YG, and it is an underexplored topic in Ayurvedic psychiatry. The present study is focused on better understanding of YG and its clinical applicability. The clinical picture of YG shows marked similarity with bipolar disorder (BD) associated with obsessive-compulsive disorder (OCD). This similarity has been explored in the following sections.

Etiology, Pathogenesis, and Prognosis of Yaksha Grahonmada and Bipolar Disorder

There is no description of specific etiology, pathogenesis, and prognosis available for YG in Ayurvedic texts. The samanya nidaana, sampraapti, and saadhyaasaadhyata (common etiology, pathogenesis, and prognosis) explained for bhutonmada is also applicable for YG. Grahavesha (affliction by evil spirit) and prajnaparadha/karma (cognitive blasphemy/deeds of the present or previous life) are explained as causative factors for bhutonmada. In grahonmada the symptoms occur suddenly without any visible or known cause. The course and prognosis of bhutonmada is unpredictable in nature.[3]

Genetic studies show that BD is one of the most inheritable of all mental disorders; with up to 80% concordance rates in monozygotic twins. Biological theories suggest abnormalities in the hypothalamic–pituitary–adrenal axis and neurotransmitter systems. Mania can be induced by sleep deprivation and a disruption of circadian rhythms. Psychosocial theories of etiology include stressful life events and dysfunctional attempts to avoid depression. It is believed that BD is caused by a complex interaction of genetic, biological and psychosocial factors.[9] The clinical course of BD varies. Psychosocial stress is known to trigger manic and depressive symptoms.[10] A rapid-cycling pattern of moods is associated with a poorer prognosis in BD.[11]

Yaksha Grahonmada Lakshanas (Signs and Symptoms of Yaksha Grahonmada)

Compared to other Ayurvedic texts, Vriddha Vagbhata in “Ashtanga samgraha” has described YG lakshana's (signs and symptoms) in a detailed way.[6] BD with OCD resembles with YG in signs and symptoms. Each and every Lakshana of YG along with its relevant modern psychiatric condition correlated as follows.

BD is marked by shifts in mood, energy, and ability to function. The course of illness is variable in BD, and symptoms range from severe mania (an exaggerated euphoria or irritability) to severe depression. In “Cyclothymia,” hypomanic episodes alternate with minor depressive episodes. People experiencing a manic state may laugh, joke, and demonstrate boundless enthusiasm.[12] The mood in a major depressive disorder (MDD) is often described by the person as depressed, sad, hopeless, and discouraged or down in the dumps. Sadness can be elicited by interview (e.g., by pointing out that the individual looks as if he or she is about to cry). Bereavement is one of the features of MDD, and the patient appears tearful in this condition.[13] “Asakrit haasya rodana” of YG denotes frequent changes of mood (mania and depression as in BD) or cyclothymia.

Asakrit swapna (hypersomnia/sleep disturbances)

Hypersomnia is an excessive sleepiness or the propensity of falling asleep during the daytime that is not solely accounted for by an inadequate amount of sleep. Among psychiatric disorders, hypersomnia appears to be most common in BD, and it persists into the inter-episode period of BD at a relatively high rate. Even outside of depressive episodes, 25% of euthymic bipolar individuals experience hypersomnia. Excessive sleepiness predicted relapse into hypomania/mania. Associations between decreased sleep and increased mania are established in the literature. There may be an as yet unexplained biological marker contributing to both excessive sleepiness and the circadian instability at the core of bipolar illness episodes. Alternatively, a homeostatic regulatory process may underlie the relationship between excessive sleepiness in the euthymic period, and reduced sleep needs in hypomania/mania, even though little is known about the mechanisms of sleep regulation in either state.[14]

Decreased need for sleep is one of the seven diagnostic criteria of bipolar mania. Although the ability to maintain energy without sleep is characteristic of mania, manic patients still likely require sleep to sustain life. Historical data suggest that manic patients, despite prolonged sleeplessness, ultimately have a physiological need for sleep. Disruption of the daily rhythm may often occur before episodes of mania in bipolar patients. Sleep disturbance, regardless of the underlying mechanism, is of importance in the management of patients with BD.[15]“Asakrit swapna” of YG denotes “hypersomnia” or “sleep disturbances” which are commonly seen in BD.

There is a natural co-occurrence of creativity and BD. BD is defined on the basis of manic symptoms of varying severity. Creativity is typically defined as behaviors or thoughts that are novel/original and adaptive/useful. Reviews of biographical material have suggested that BD is significantly overrepresented among samples of authors, poets, and visual artists. According to a study, 8.2% people in creative professions (including architecture/design, musical composition, musical performance, theater, expository writing, fiction writing, and poetry) appeared to have had experiences of mania. BD was over-represented in the most creative occupations, such as painting, writing, and lighting design. Many people with BD appear to be highly creative. Alcohol and drug comorbidity may be particularly prevalent among highly creative bipolar populations.[16] Individuals with Mania become involved in pleasurable activities and experience an intense feeling of well-being. The individual with mania displays unparalleled artistic talents such as writing, painting, and dancing.[12] “Nritya, geeta, vaadya, paatha, kathaa ratim” of YG denotes euphoria of manic episode.

OCD is the most commonly seen comorbid anxiety disorder in bipolar patients. Among Bipolar I or II, 21% had comorbid OCD. Those with pure OCD have more checking compulsions while those with comorbidity exhibit more obsessions that are classified as “others” which they described as “existential, philosophical, and/or superstitious.” High comorbidity rates for obsessive-compulsive symptoms in BD patients (38.7%) are found. The most common obsessions were contamination, religious, and aggressive obsessions and the most common compulsions were cleaning/washing and counting compulsions in BD-OCD group.[17] Excessive showering, bathing, grooming, cleaning, or washing compulsions and contamination obsessions of OCD resemble with “snaana, maalya, dhoopa, and gandha ratim” of YG. This symptom of YG denotes the obsessive-compulsive features in a patient of BD.

Viplutaaksha (abnormal eye movements)

Eye movements are any shift of position of the eye in its orbit. Eye movements serve to stabilize images on the retina and to keep objects of interest on the fovea. Bipolar patients have been shown to perform more poorly than normal controls on a smooth pursuit eye movements task.[18] Eye movements have been used to identify the characteristics of motor and cognitive alteration in MDD and BD. Depressed and bipolar patients have been characterized by an increase in reaction time. Among BD patients, only those who are in their depressive phase have longer latency. Bipolar depressed patients present psychomotor retardation and inhibition deficit.[19] “Vipuluaaksha” of YG may denote abnormal eye movements seen in BD patients.

Trasta and rakta nayana (tired and reddish eyes)

Decreased need for sleep and/or sleep disturbances is one of the diagnostic criteria of bipolar mania.[15] Sleep deprivation affects a number of facial characteristics that observers relate to fatigue. Sleep deprivation is readily observable from a set of facial cues. Droopy/hanging eyelids, red eyes, dark circles under the eyes, and pale skin are indicative of both sleep deprivation and fatigue. In addition, there was a correlation between looking fatigued and looking sad. Eye-related behaviors are indicative of sleepiness and that one looks to the eyes to evaluate fatigue.[20] “Trastaaksha” and “Taamraaksha”/”Rakta nayana” of YG denotes tired and reddish eyes which may be due to sleep deprivation or sleep disturbances seen in BD patients.

Druta mati and druta gati denotes agitation or restlessness or hyperactivity or increased psychomotor activity found in the patients of BD. Research indicates that psychomotor agitation (PMA) which includes various unintentional motor activities such as fidgeting, pacing, and handwringing. PMA and BD were associated with each other.[21] PMA is a pathological condition characterized by a significant increase in ideational, emotional, motor, and/or behavioral activity. Definitions of agitation generally entail the presence of “exceeding restlessness associated with mental distress” and “excessive motor activity associated with a feeling of inner tension.” Purposeless motor behavior is one of the key features of agitation. In patients with BD, agitation is often the main clinical manifestation during manic and mixed states. The prevalence of PMA of 87.9% in BD I and 52.4% in BD II has been reported. Agitation is the third most frequent symptom in mania, with prevalence of 87%. The signs of PMA generally include motor restlessness, hyperreactivity, irritability, and inappropriate motor activity. Poor motor control, pacing, and aimless wandering are also features of PMA.[22]

Rakta vastra ratim (fond of red color dresses/flamboyant)

Modes of dress often reflect the person's grandiose yet tenuous grasp of reality. Dress in manic patients may be described as outlandish, bizarre, colorful, and noticeably inappropriate. Makeup may be garish and overdone during manic episodes.[12] Red color has highest affective value and reveals uninhibited expression. Emotionally, the red end of the spectrum is exciting. Red colors tend to increase bodily tension and to stimulate the autonomic nervous system.[23] The person suffering with mania usually dressed up in gaudy and flamboyant clothes.[24] Miscellaneous obsession like “colors with special significance” (preferring particular colors) is also one of the features of OCD which may be found comorbid with BD.[3] Preference to wear red color dress indicates the exteriorization, centrifugal dispersion, disinhibition, and euphoria of manic episode.

”Sagarvam mattamiva gacchantam” denotes “inflated self-esteem” or “grandiosity” seen in mania. “Kasmai kim dadaami vaadinam” denotes “over generosity” or “giving away money or things indiscriminately” seen in mania. Grandiosity (inflated self-esteem) is apparent in both the ideas expressed and the person's behavior during manic episode. People with mania may exaggerate their achievements or importance by stating that they know famous people, or believe they have great powers. The boast of exceptional powers and status can take delusional proportions during mania. Grandiose persecutory delusions are common. Manic patients know no strangers, and energy and self -confidence seem boundless. Elaborate schemes to get rich and famous and acquire unlimited power may be frantically pursued, despite objections, and realistic constraints. People in the manic phase are busy during all hours of the day and night, furthering their grandiose plans. To the manic person, no aspirations are too high, and no distances are too far. No boundaries exist to curtail them. In the manic state, a person often gives away money, prized possessions, and expensive gifts, may throw lavish parties, frequent expensive nightclubs and restaurants, and spend money freely on friends and strangers alike. In hypomania, people have voracious appetites for social engagement, spending, activity, spending large sums of money on frivolous items, giving money away indiscriminately, or making foolish business investments which can leave an individual or family penniless.[12]

”Bahu bhaashinam” of YG denotes “pressure of speech” or excessive speech seen in mania whereas “Alpa vaak” of YG denotes “diminished speech” or social withdrawal seen in depression. Both bahu bhaashinam and alpa vaak in a same patient denotes BD (manic and depressive episodes). Flight of ideas is a nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually based on understandable associations or plays on words in mania. Speech is rapid, verbose, and circumstantial (including minute and unnecessary details) during manic episode. In severe mania, speech may be disorganized and incoherent. Speech is not only profuse but also loud, bellowing, or even screaming. One can hear the force and energy behind the rapid words. As mania escalates, flight of ideas may give way to clang associations. Clang associations are the stringing together of words because of their rhyming sounds, without regard to their meaning.[12] Depression refers to a range of mental problems characterized by loss of interest and enjoyment in ordinary experiences, low mood and associated emotional, cognitive, physical, and behavioral symptoms. Reduced psychomotor activity, social withdrawal, anhedonia, and decreased ability to function in occupational and interpersonal areas are the features of depression.[1] “Alpa vaak” of YG denotes depressive episode in a patient suffering with BD.

Stree lolupam (hypersexuality)

The evidence that sexuality is often increased in adults with BD during hypomanic or manic episodes. Previous studies have found increased sexuality in manic or hypomanic patients compared to major depressive controls. In addition, 40% of the Bipolar I and II patients in a study reported elevated sexuality as an enduring inter episodic trait. Increased interest in sex and frequent change of sexual partners were more common among patients with BD compared with patients with unipolar depression and normal controls. Bipolar I patients placed more value on sex, had more interest in sex, and desired and engaged in intercourse more frequently than Bipolar II or Comparison patients. According to a study, 65% of manic episodes were characterized by increased sexuality and 40% of cyclothymic patients had “episodic or unexplained promiscuity or extramarital affairs.” Bipolar II patients manifested diverse types of sexual excess including sexual infidelity, overt bisexuality, and sexual activity many times per day.[25] “Stree lolupam” of YG indicates hypersexuality of manic episode.

Hrushtam/tushtam (euphoria/positive mood)

The euphoric mood associated with mania is unstable. During euphoria, the manic patient may state that he/she is experiencing an intense feeling of well-being, is “cheerful in a beautiful world,” or is becoming “one with God.” The overly joyous mood may seem out of proportion to what is going on, and cheerfulness may be inappropriate for the circumstances. People with mania may laugh, joke, and talk in a continuous stream, with uninhibited familiarity. Elaborate schemes to get rich and famous and acquire unlimited power may be frantically pursued, despite objections, and realistic constraints. Excessive phone calls and E-mails are made, often to famous and influential people worldwide. The person during full-blown mania constantly goes from one activity, place, or project to another. Flowery and lengthy letters are written, and excessive phone calls are made. Individuals become involved in pleasurable activities that can have painful consequences. Themes in the communication of the individual with mania may revolve around extraordinary sexual prowess, brilliant business ability, or unparalleled artistic talents (e.g., writing, painting, and dancing).[12] All these features denote “euphoria” in mania which is equivalent to “hrushtam”/”tushtam” of YG.

Avyatham (reduced pain intensity)

Chronic pain is defined as an unpleasant sensory and affective experience associated with actual or potential tissue damage. BD is characterized by periods of increased energy and positive affect and may be associated with reduced pain intensity. Positive affect in patients with BD may also be widely variable, depending on their current point in the bipolar cycle of depression, hypomania, or mania. Positive affect decreases pain intensity in patients with chronic pain. The fact that 64% of patients with bipolar pain with chronic pain recalled experiencing reduced pain during mania. Patients perceive a reduction in pain during manic or hypomanic episodes. When the manic phase resolves, increases in pain may become particularly noticeable, contributing to a cycle of over activity and pain.[26] “Avyatham” of YG indicates reduced pain intensity of manic episode.

Madya amisha priyam (alcohol abuse and fond of meat)

BD is robustly associated with smoking and substance use disorders. These relations have been shown for both Bipolar I and II subtypes and are particularly strong for lifetime substance dependence diagnoses, including nicotine, alcohol, and drug dependence. Consistent with prior reports, lifetime BD was associated with lifetime nicotine, alcohol, and drug dependence. Patients with both BPD and PMA exhibited especially high rates of comorbid substance dependence.[21] “Madya priyam” of YG denote “alcohol abuse” which is a common comorbid condition of BD.

The person suffering with YG craves for meat which may indicate a deficiency of various nutrients in the body (so cravings develop toward such type of foods which may correct the nutritional deficiency). There are no direct references related to cravings for particular food items in psychiatric disorders, but the latest research shows that various nutritional deficiencies might produce antisocial and offending behavior.[27] The most common nutritional deficiencies seen in patients with mental disorders are of omega-3 fatty acids, B vitamins, minerals, and amino acids. Some biochemical abnormalities in people with BD include oversensitivity to acetylcholine, excess vanadium, Vitamin B deficiencies, a taurine deficiency, anemia, omega-3 fatty acid deficiencies, and Vitamin C deficiency. A deficiency of taurine may increase a bipolar patient's manic episodes. In addition, 80% of bipolar sufferers have some Vitamin B deficiencies.[28] Poor intake of food which is common in alcohol abuse; alcohol impairs digestion and absorption of many nutrients from the small intestine. These include B1, B6, B12, choline, and folic acid as well as some minerals; and with liver impairment absorption of the fat-soluble Vitamins A, D, E, and K is also reduced.[29]

Alcohol also causes a chemical imbalance in the brain involving the neurotransmitters dopamine and serotonin. Dopamine cannot be obtained directly from food, but tyrosine is abundant in several protein-rich foods such as chicken, turkey, avocado, seeds and nuts. By eating foods rich in tyrosine, the brain will be able to synthesize dopamine. Chicken, red meat, dairy products, and eggs all contain the amino acid tryptophan, which the body can convert into niacin. Foods such as fish, eggs, chicken, turkey, and red meat supply the body with adequate amino acids.[29] By considering all these facts, it can be assumed that the cravings toward nonvegetarian food items as mentioned in YG (amisha priyam) denotes the underlying deficiency of folic acid, iron, essential amino acids, proteins, vitamins, minerals, and various other micronutrients. The underlying anemia and nutritional deficiencies in people with BD with substance abuse (alcohol abuse) may show cravings for nonvegetarian food items.

Rahasya bhaashinam (revealing secrets/pressure of speech)

Manic patients often demonstrate boundless enthusiasm, treat others with confidential friendliness, and incorporate everyone into their plans and activities. Speech in mania is rapid, verbose and circumstantial (including minute and unnecessary details). The content of speech in mania is grossly inappropriate with clang associations.[12] “Rahasya bhaashinam” of YG may indicate “pressure of speech” or “circumstantial speech” or “inappropriate excessive speech” commonly seen in the manic episode.

Chalitaagra hastam (stereotypy or mannerisms of hands)

Stereotypies are specific movements (e.g., rocking and hand flapping or waving) or more broadly to heterogeneous self-directed, repetitive behaviors, activities, and interests (e.g., covering ears, staring at an object, pacing, object fixation, playing in a fixed pattern, and picking skin). Stereotypic movements include handshaking, posturing, flapping or waving, opening and closing of the hands, finger writhing, arm flapping, and flexion and extension of the wrists. They may occur in conjunction with other activities (e.g., body rocking, leg shaking or kicking, facial grimacing, mouth opening, neck extension, and involuntary noises), but the hand/arm movements are dominant. In 57 individuals (aged 7 years and older) of stereotypies, 9% had obsessive-compulsive behaviors.[30] A large range of motor disturbances is associated with OCD psychopathology, including catatonic signs, motor slowness and hyperkinesia. Abnormalities of motor coordination and involuntary movements, typical neurological soft signs were also found in about 30% of patients with OCD. The correlation of the severity of OCD symptoms with disturbances in hand motor performance in OCD is of special interest.[31] “Chalitaagrahastam” of YG denote either stereotypic movements or mannerisms or habits or obsessive-compulsive behaviors or motor tics or hyperkinesia in a patient of OCD with BD.

Dvijati vaidya paribhavam (hostility)

Aggression is an overt action intended to harm. Violence denotes aggression among humans. Agitation is an excessive motor or verbal activity. Hostility denotes unfriendly attitudes. Overt irritability, anger, resentment, or verbal aggression is manifestation of hostility. The prevalence of violent behavior in BD is at least as high as in schizophrenia. Clinicians have been aware of the problems with violent behavior in BD for a long time. Aggression is associated with irritability, uncooperativeness, impatience, and lack of insight. Aggression is a feature of manic and mixed episodes of BD, develops in the context of irritability, and may be an enduring individual trait.[32] “Dvijati vaidya paribhaavinam” of YG indicates aggressiveness/hostility/resentment commonly seen in mania/BD.

Sutejasam (bright looks), shubha gandham (emitting good smell), alpa rosham (diminished anger), sahishnu (patience), etc. various virtuous conduct/excessive morality related signs and symptoms of YG does not show any similarity with manic episode/BD, but they may indicate the obsessive-compulsive features of OCD comorbid with BD. Religious obsessions such as excessive concern with right or wrong, excessive concern with sacrilege and blasphemy, excessive morals, miscellaneous obsession like fear of not saying just the right thing, colors with special significance, cleaning and washing compulsions such as excessive showering, bathing, grooming, cleaning obsessive-compulsive features [3] may resemble sutejasam, shubha gandham, alpa rosham, sahishnu, etc. features of YG. The person of BD during mixed episode or hypomania or when associated with OCD may show the features such as sutejasam, shubha gandham, alpa rosham, and sahishnu of YG.

Comorbidity of Bipolar Disorder and Obsessive-Compulsive Disorder

A strong association between OCD and mood disorders has been reported in recent studies. Depression is the most common comorbid mood disorder in OCD with rates ranging from 13% to 75%. BD is common in patients with OCD with prevalence rates ranging from 10% to 20%. OCD is known to worsen in depression and improve in hypomania/mania. OCD with BD is associated with a significantly higher rate of sexual, religious, and symmetry obsessions and repeating, counting, and ordering/arranging compulsions. Episodic course is typical of OCD when comorbid with BD. The OCD with BD group had a higher rate of miscellaneous compulsions. Higher rates of religious and sexual obsessions and obsessions with symmetry, as well as an inconsistent association with ordering/arranging compulsions and checking rituals are found in OCD with BD group. Miscellaneous obsessions, such as philosophical, existential, bizarre, and superstitious beliefs, were more common in the bipolar OCD group in according to a study.[33]

Conclusion

“ YG“ is one among 18 types of grahonmada. The clinical picture of YG shows similarity with BD associated with OCD. Various obsessive-compulsive features along with the features of mania and depression are seen in YG symptomatology.